Articles for therapists and counsellor about CBT - Cognitive Therapy. These posts are intended to help the beginning CBT practitioner and also provide food for thought for experienced cognitive therapists. Provided by UKCP Central London therapist and accredited CBT practitioner and supervisor Tim LeBon.

Wednesday, 12 June 2013

The other day I had an unbalanced yet illuminating psychotherapy day. Of the 5 clients I saw, 4 were just starting therapy, either having an assessment or in their early sessions, and the other was at session 12, near the end of her therapy journey.

For the client nearing the end of therapy , the session almost ran itself. We quickly settled on an agenda, reviewed home practice and then the client herself was able to apply the formulation and new ways of thinking and behaving to her issues. It felt like real teamwork, and we both left the session feeling really good about it. I felt full of energy and enthusiasm

With the other clients it was a different story. I was spending a lot of time and energy keeping the structure of the session tight, dealing with any doubts the client had about CBT and trying to match what they were saying and what they wanted with how CBT understands things and what it can offer. I do not know how these clients felt about the sessions, but I felt drained and wishing I could have done a better job.

The contrast could not have been greater. Yet that the first client had been just like the other clients a few months ago. She and I had climbed the CBT mountain and now it was all downhill, in a good way.

My question is this. How can we CBT therapists get to the top of the CBT mountain more quickly? How can we get to that wonderful feeling of teamwork, collaboration and fruitful work being done in 3 sessions rather than 5? How can we have less clients needlessly dropping out of treatment?

Here are some thoughts

Explain to the client that the first sessions aren't so much about curing the problem as understanding it-this sets the scene for formulation work.

Use disorder-specific models when you can - they provide a compass for you to follow

Use metaphors, similes and stories as part of the psycheducation. For example if dealing with OCD, you may ask the client to think of OCD as being like a school bully that keeps asking for more

Give appropriate reading as part of psychoeducation - my experience here is that less is more, and a sheet has much more chance of being read and digested than a book.

Ask the client to be actively involved in psychoeducation. "Which parts of the article apply to you?" "What are you unsure about?" are good questions.

Use guided discovery to convey the CBT model and aspects of it

Look for examples in the client's story that fits with CBT and draw their attention to it

Summarise more frequently than in later sessions , and ask the client to summarise back

Ask the client at the end and beginning of session what was most important thing from the session (or previous session)

Be structured right from the start and explain why CBT is structured. This gives you permission to politely interrupt the client if necessary

Set home practice right from the start of therapy and explain its vital importance

Ask the client to set their therapy goals early on in therapy and to grade where they are on them and keep coming back to them

What else do you think is important in the early sessions of therapy to help to get to the top of the CBT mountain more quickly?

Thursday, 21 March 2013

I recently attended Chris Irons' one-day workshop on Compassion-Focussed Therapy (CFT). I was interested in learning about yet another third wave CBT therapy and also wanted to find out the answer to a number of questions, such as

2. Paul Gilbert, the founder of CFT, is influenced not just by CBT but also by attachment theory, neuroscience, Jung and social and developmental psychology. Whilst CBT is very helpful for many people, Gilbert found that some self-critical clients really struggled with CBT. They could relate to alternative perspectives t intellectually but struggled to really believe more positive ideas about themselves with their heart. This "head heart lag" occured most when clients had no experiences of nurturing to draw on. They couldn't feel positive about themselves, because they had no experience of feeling positive about themselves to draw on. This led Gilbert to move beyond CBT and develop CFT.

The "old brain" is the fast automatic systems that occur in other animals, the "new brain" is the slower neocortex which more developed in humans and gives us our power to imagine, reason and plan and use language.The three emotion regulation systems are particularly important in CFT and arecolour-coded in CFT to help clients remember them.

The RED system. THREAT and PROTECTION. NEGATIVE EMOTIONSThe world is a dangerous place, So it's good we have a part of our brain dedicated to protecting us.When threatened, a stress response will kick off the "old brain" and we will feel a strong urge to get away. The new brain is also part of the RED threat system - it worries and ruminates to try to help us deal with threats.The Red Threat System is not a bad thing. You wouldn't want to be without it, But you can have too much of a good thing. The question to ask is - is your threat system sometimes in overdrive? Would it be helpful to develop your own switch which could turn the threat system down a notch or two sometimes? For those who are strongly self-critical and experience high levels of shame as well as those who experience other psychological problems, the answer may well be "YES".The BLUE system. ACHIEVEMENT and PLEASURE. UNQUIET POSITIVE EMOTIONSOur body requires food, our species needs us to have sex in order to continue, society need us to achieve certain things in order for it to flourish. It makes sense that our brain motivates us to seek pleasure and achievement and rewards us when we do so. When we get depressed a lot of people have too little achievement and pleasure in their life. CBT and Behavioural Activation can help depressed people redress the balance. With other people, though, the blue system can become a problem. An addict may be too focussed on pleasure, the perfectionist on achievement. Self-esteem that is contingent on achievement can be as problem. If "You only sing when you're winning" is a problem in a world when not everyone can be winners. So as with the RED system, the BLUE system is both necessary and potentially dangerous.

The GREEN system SAFENESS and SERENITY. CALM POSITIVE EMOTIONSAs well as "unquiet" positive emotions such as excitement and adventure we can also have positive emotions associated with safety, contentment, serenity and peace.These calm positive emotions are linked to attachment and caring. Clients who have lacked secure attachment in childhood and have had insufficient emotional nourishment may have a deficit in this system. CFT aims to make the green system more powerful.A CFT therapist will explain these three systems to clients and ask this key question

If we were to draw your three systems as circles, what would be their relative size?

For many self-critical clients who experience large amounts of shame, the green system would be very small and the read system very large.

4. Shame is different from and more problematic than either guilt or embarrassment.Guilt occurs when you think you done something wrong and feel you need to make amends,. Guilt is linked to caring mentality and can be a good thingEmbarrassment occurs when you feel other people will judge what you have done adversely, but the incident doesn't sum you up - you may have walked home with your flies undone, but that doesn't say much about you as a person. It is something you i can tell other people about.Shame on the other hand is when you think that others will judge you adversely, and their judgement does encapsulate you as a person. You find it very difficult to tell other people about shameful episodes. Shame is therefore a more tricky emotion and is more closely linked with hopelessness, suicide and less successful therapy outcomes. So if CFT can help people with high levels of shame, it will make an important contribution.Shame is often divided into external shame - shame in other's eyes - and internal shame - feeling ashamed of ourselves,

5. A simple idea that can help empower the green system and hence reduce self-criticism and shame isIt is not your faultEvolution has left us with a flawed system. The old brain and new brain do not always interact well. The three emotional regulation systems aren't always in balance. You didn't choose your genes. You didn't choose which family you were born into. You didn't choose whether the green calming system developed during childhood. It's not your fault

6. CFT helps clients to develop both mindfulness and compassion.CFT uses a range of therapeutic techniques familiar to the CBT therapist including psychoeducation, formulation, listening, behavioural experiments, exposure, agenda setting and home practice. Two skills that are particularly prominent in CFT are mindfulness meditation and compassion meditation.Mindfulness and compassion are different skills using different parts of the brain.The mindful brain is a new brain capacity . It increases one's capacity to shift attention and awareness. and purposefully focus. You can have mindfulness without compassion - think of a sniper.Compassion on the other hand is an old brain capacity. You can have compassion without mindfulness -think of a parent running into a house on fire to save their child. CFT targets both.

7.Compassion can be a powerful antidote to shame. You can help clients develop compassion through imagery and meditation. This podcast provides an example of compassion meditation.

8 Often clients will not like compassion at first. You need to expect resistance - this is part of the work. These people are uncomfortable with compassion, they aren't used to it, it may stir up difficult memories- you have to work with this. It's like working with a phobic -you don't give up just because they don't want to be exposed to their fear.Clients may have a lot of metacognitive beliefs you have to deal withFor example

Self-criticism keeps me from being selfish and lazy

To discover your client's specific beliefs about the benefits of self-criticism ask them

"What concerns would you have about the possibility of not being self-critical at all?"

You need to challenge beliefs about the benefits of self-criticism. Remind them that compassionate people like Nelson Mandela are strong. Ask them if they would like their self-critic to be the teacher of a child they loved who was struggling with maths. Tell them that their aim is not to lose self-control and do whatever they like, but to replace the harsh self-critic (the "poisoned parrot") with a gentle compassionate internal self-corrector - perhaps like Dumbledoore. 9. It's helpful to use metaphors and stories.This Native American story about feeding the good wolf can help foster hope and the realisation that CFT takes practice in compassion - and also the idea that it compassion is a choice.10. There is growing evidence for the effectiveness of CFT. Most of the evidence comes from group CFT and as yet there are no randomised control trials. So whilst CFT promises to help with some of the difficult cases that CBT finds most tricky, it would be premature to abandon CBT altogether.

You can learn more about Compassion Focussed Therapy and get lots of free downloads and other resources at Compassionatemind.co.uk. This link provides many useful and free Scales

From a clinical perspective, jealousy has similarities with both OCD and GAD and I find
a metacognitive approach helpful.

It's certainly a common problem and will sometimes be the underlying problem in referrals for depression and anxiety so its definitely worth having some ideas up your sleeve regarding how to work with such clients.

Wednesday, 13 February 2013

Yesterday I attended an extremely useful workshop given by Professor Ed Watkins from the University of Exeter yesterday about how Rumination-Focussed Cognitive Behavioural Therapy (RFCBT) can help clients with both depression and anxiety-related disorders.

In this post I will present 10 things I learnt about RFCBT

1) Worry and Rumination are quite similar - the main difference is that worry tends to be future-oriented and rumination past-oriented. "Repetitive thinking" (RT) can be used to cover both processes; clinically you should use whatever term makes sense to the client. Clients may talk about "dwelling on", "brooding", "going over things again and again", "stewing on things", "chewing things over", "procrastinating" - notice what term they use and stick with it.

2) Repetitive thinking is often a key pathological process. It can maintain both anxiety and depression. Consequently identifying it, labelling it, and changing it can be a key step in shifting depression and anxiety

3) Rumination and worry can be thought of as part of avoidance which is known to be part of both depression and anxiety. Rumination and worry tend to involve withdrawal from others, reduced activity and taking less risk - all characteristics of major depression. Worrying can be an alternative to confronting the thing one is worried about.

4) Rumination and worry are quite normal - we all do it - and need not always be unhelpful. Whereas Adrian Wells's Metacognitive Therapy (MCT) tends to view all rumination and worry as pathological, Watkins' RFCBT appears more attuned to the possibility that there is some purpose to it, and sometimes it may actually be helpful. Even if it is not helpful, its useful to identify its aim (Padesky's there's a good reason for what you are trying to do idea) and substitute more helpful ways of achieving this goal.

5) Functional analysis is a key technique in determining the purpose and nature of rumination and worry for an individual client. Functional analysis involves identifying the antecedents, behaviours and consequences (ABC) of the problem (in this case repetitive thinking). Antecedents - "tell me about a recent time when you found yourself chewing things over. What kicked it off? what did you notice first? what was going on in your body? where were you? what was going through your mind? who were you with?" These are all good questions to elicit the antecedents.Behaviour - "what happened next? how long did it last? what ended it? were you thinking about the past a lot? were you trying to figure out the meaning of things? (rumination) were there a lot of what-ifs? (worrying)Consequences "Did it help? In what ways was it useful? In what ways was it not useful? What was it trying to achieve? What happened as a result? Did you feel different? What were the long-term consequences? What would you like to happen? I this way both the positive and negative consequences of repetitive thinking can be identified.
Functional analysis begins in the assessment session and may be augmented by asking the client to keep a diary. The diary would focus on the problem behaviour. Notice that rumination and worry are treated as behaviours.

6) Functional analysis will draw out the range of repetitive thinking which the client is currently doing. It will also clarify for both client and therapist the ways in which it is helpful or unhelpful. Most often the helpful parts which actually be problem-solving, planning or decision-making. It may be that sometimes it may be useful to come to terms with a loss, or be part of a grieving process. In this way RFCBT can be seen as being a guided discovery towards something like Butler and Hope's Worry Decision Tree. A logical follow-up will be further worked aimed at
1) distinguishing between unhelpful and helpful repetitive thinking
2) reducing the unhelpful processes (unhelpful repetitive thinking)
3) coaching in planning, problem-solving and decision-making

7) Repetitive thinking is best explained as a bad or unhelpful habit.
Framing RT as a habit is very often a useful way of socialising clients into RFCBT. We all have bad habits and we all know that they can be difficult to change, but they can be changed. This way of thinking about RT gives the right message.

Rumination and worry are generally unhelpful, and you can change them, and we will need to work to change them, and it may require quite a lot of practice.

An alternative message given in more mindfulness-based approaches would be that of a skill - that learning to ruminate or worry less is like learning a new skill).

8) RFCBT proposes a number of ways to reduce unhelpful repetitive thinking.
These include
i) Becoming more aware of the triggers
This follows from the "A" part of functional analysis. For example, a client may notice that a trigger to rumination is being on their own on their walk to work.
ii)Altering environmental contingencies
For example, the above client may be encouraged to try out listening to cheerful music on their way to work..
iii) Changing processing style
Repetitive thinking involves abstract and very often uncompassionate thinking. can be countered by exploring flow experiences (point 8) and learning to be more compassionate (point 9)

9) Modelling and scheduling experiences of deep absorption and engagement (flow) can provide an effective contrast to repetitive thinking. Ask the client to recall an experience of deep absorption - it may be doing a sport, a hobby or at work. You can then either schedule more activities like that (flow activities scheduling) or help the client get back in touch with those feelings using imagery.
a) Ask the client to notice the triggers of rumination or worry
b ) Get back in touch with their flow experience -
c) Return to the task that was interrupted by the rumination or worry.
In this way recreating the flow experience in imagination is not just a distraction - it is teaching the client to get back in touch with a very concrete, focussed processing style which they can use to be more effective.

10) Compassionate Mind training is another way to change thinking style in a helpful way. Many ruminators and worriers are self-critical. If they can learn to be kinder to themselves, this will change their style of thinking. Paul Gilbert and Deborah Lee have done a lot of work on compassionate mind training, for example involving developing an image of the "perfect nurturer" and bringing it to mind when you need it. RFCBT's approach is slightly different in that it involves real experiences of compassion - for example when they had been compassionate to some else. Through imagery work the client is invited to get in touch with the feelings and thoughts of compassion. They can then practice this through homework and work through a hierarchy of more difficult times to bring compassion. Often it will be hardest to be self-compassionate in which case this will be at the top of the hierarchy.

To sum up:- RFCBT is an evidence- based, short-term trans-diagnostic approach which can help with depression and anxiety. It can almost certainly also be useful in dealing with other problems such as PTSD and anger-management. Many of its techniques (functional analysis, guided discovery, behavioural experiments, imagery, homework setting, exposure hierarchy will be familiar to the CBT practitioner. It also has similarities but also differences with Wells's Megacognitive Approach, Gilbert's Compassion-Focussed therapy, Butler and Hopes Worry Tree and Positive Psychotherapy approaches enhancing flow and engagement.